A thorough history and physical examination should be obtained/ performed in patients presenting with Heart Failure to identify cardiac and noncardiac disorders or behaviors that might cause or accelerate the development or progression of Heart Failure.

A thorough history and physical examination should be obtained or performed

Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea.

Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea.

Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea.

Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea.

Volume status and vital signs should be assessed at each patient encounter. This includes serial assessment of weight, as well as estimates of jugular venous pressure and the presence of peripheral edema or orthopnea.

For patients at risk of developing Heart Failure, natriuretic peptide biomarker–based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of left ventricular dysfunction (systolic or diastolic) or new-onset Heart Failure.

For patients at risk of developing Heart Failure, natriuretic peptide biomarker–based screening followed by team-based care, including a cardiovascular specialist optimizing GDMT, can be useful to prevent the development of left ventricular dysfunction (systolic or diastolic) or new-onset Heart Failure.

Patients with suspected or new-onset Heart Failure, or those presenting with acute decompensated Heart Failure, should undergo a chest x-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms.

A 2-dimensional echocardiogram with Doppler should be performed during initial evaluation of patients presenting with Heart Failure to assess ventricular function, size, wall thickness, wall motion, and valve function.

Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with Heart Failure who have had a significant change in clinical status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy.

Repeat measurement of EF and measurement of the severity of structural remodeling are useful to provide information in patients with Heart Failure who have had a significant change in clinical status; who have experienced or recovered from a clinical event; or who have received treatment, including GDMT, that might have had a significant effect on cardiac function; or who may be candidates for device therapy.

Invasive hemodynamic monitoring with a pulmonary artery catheter should be performed to guide therapy in patients who have respiratory distress or clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment.

Routine use of invasive hemodynamic monitoring is NOT recommended in normotensive patients with acute decompensated Heart Failure and congestion with symptomatic response to diuretics and vasodilators.

In all patients with a recent or remote history of MI or acute coronary syndrome and reduced EF, angiotensin-converting enzyme (ACE) inhibitors should be used to prevent symptomatic Heart Failure and reduce mortality. In patients intolerant of ACE inhibitors, angiotensin-receptor blockers are appropriate unless contraindicated.

In all patients with a recent or remote history of MI or acute coronary syndrome and reduced EF, angiotensin-converting enzyme (ACE) inhibitors should be used to prevent symptomatic Heart Failure and reduce mortality. In patients intolerant of ACE inhibitors, angiotensin-receptor blockers are appropriate unless contraindicated.

In all patients with a recent or remote history of MI or acute coronary syndrome and reduced EF, angiotensin-converting enzyme (ACE) inhibitors should be used to prevent symptomatic Heart Failure and reduce mortality. In patients intolerant of ACE inhibitors, angiotensin-receptor blockers are appropriate unless contraindicated.

In all patients with a recent or remote history of MI or acute coronary syndrome and reduced EF, angiotensin-converting enzyme (ACE) inhibitors should be used to prevent symptomatic Heart Failure and reduce mortality. In patients intolerant of ACE inhibitors, angiotensin-receptor blockers are appropriate unless contraindicated.

In patients with structural cardiac abnormalities, including LV hypertrophy, in the absence of a history of MI or ACS, blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic Heart Failure.

blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic HF.

To prevent sudden death, placement of an implantable cardioverterdefibrillator (ICD) is reasonable in patients with asymptomatic ischemic cardiomyopathy who are ?40 days post-MI, have an LVEF of ?30%, are on appropriate medical therapy, and have a reasonable expectation of survival with a good functional status for >1 year.

placement of an implantable cardioverterdefibrillator (ICD) is reasonable

Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF of ?40% who develop symptoms of Heart Failure or who have a history of diabetes mellitus, unless contraindicated.

The selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal AF should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. (

The selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) should be individualized

Chronic anticoagulation is reasonable for patients with chronic Heart Failure who have permanent/persistent/paroxysmal AF but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). (

Drugs known to adversely affect the clinical status of patients with current or prior symptoms of Heart FailurerEF are potentially harmful and should be avoided or withdrawn whenever possible (eg, most antiarrhythmic drugs, most calcium channel–blocking drugs [except amlodipine], nonsteroidal anti-inflammatory drugs, or thiazolidinediones).

Long-term use of infused positive inotropic drugs is potentially harmful for patients with Heart FailurerEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment

Long-term use of infused positive inotropic drugs is potentially harmful

The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors OR ARBs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic Heart FailurerEF to reduce morbidity and mortality.

The clinical strategy of inhibition of the renin-angiotensin system with ACE inhibitors OR ARBs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients

The clinical strategy of inhibition of the renin-angiotensin system with ARNI in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic Heart FailurerEF to reduce morbidity and mortality.

The clinical strategy of inhibition of the renin-angiotensin system with ARNI in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients

The use of ARBs to reduce morbidity and mortality is recommended in patients with prior or current symptoms of chronic Heart FailurerEF who are intolerant to ACE inhibitors because of cough or angioedema.

Ivabradine can be beneficial to reduce Heart Failure hospitalization for patients with symptomatic (NYHA class II-III) stable chronic Heart FailurerEF (LVEF ?35%) who are receiving GDEM, including a beta blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of ?70 bpm at rest.

ARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors as first-line therapy for patients with Heart FailurerEF, especially for patients already taking ARBs for other indications, unless contraindicated.

ARBs are reasonable to reduce morbidity and mortality as alternatives to ACE inhibitors

Addition of an ARB may be considered in persistently symptomatic patients with Heart FailurerEF who are already being treated with an ACE inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated.

Use of 1 of the 3 beta blockers proven to reduce mortality (ie, bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of Heart FailurerEF, unless contraindicated, to reduce morbidity and mortality.

Use of 1 of the 3 beta blockers proven to reduce mortality (ie, bisoprolol, carvedilol, and sustained-release metoprolol succinate)

Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with NYHA class II–IV and who have LVEF of ?35%, unless contraindicated, to reduce morbidity and mortality. Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. Creatinine levels should be ?2.5 mg/dL in men or ?2.0 mg/dL in women (or estimated glomerular filtration rate >30 mL/min/1.73 m2) 2) and potassium levels should be <5.0 mEq/L. Careful monitoring of potassium levels, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency.

Aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with NYHA class II–IV and who have LVEF of ?35%, unless contraindicated, to reduce morbidity and mortality. Patients with NYHA class II should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. Creatinine levels should be ?2.5 mg/dL in men or ?2.0 mg/dL in women (or estimated glomerular filtration rate >30 mL/min/1.73 m2) 2) and potassium levels should be <5.0 mEq/L. Careful monitoring of potassium levels, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency.

Careful monitoring of potassium levels, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency.

Aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute MI in patients who have LVEF of ?40% who develop symptoms of Heart Failure or who have a history of diabetes mellitus, unless contraindicated.

A combination of hydralazine and isosorbide dinitrate can be useful to reduce morbidity or mortality in patients with current or prior symptomatic Heart FailurerEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated.

The selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal AF should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin.

individualize the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal AF

Chronic anticoagulation is reasonable for patients with chronic Heart Failure who have permanent/persistent/paroxysmal AF but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation).

Drugs known to adversely affect the clinical status of patients with current or prior symptoms of Heart FailurerEF are potentially harmful and should be avoided or withdrawn whenever possible (eg, most antiarrhythmic drugs, most calcium channel–blocking drugs [except amlodipine], nonsteroidal anti-inflammatory drugs, or thiazolidinediones).

Drugs known to adversely affect the clinical status are potentially harmful and should be avoided or withdrawn whenever possible

Long-term use of infused positive inotropic drugs is potentially harmful for patients with Heart FailurerEF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage D starting on page 34).

Long-term use of infused positive inotropic drugs is potentially harmful except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment

Coronary revascularization is reasonable in patient with CAD in whom symptoms (angina) or demonstrable myocardial ischemia is judged to be having an adverse effect on symptomatic Heart FailurepEF despite GDMT.

ICD therapy is recommended for primary prevention of sudden cardiac death (SCD) to reduce total mortality in selected patients with nonischemic DCM or ischemic heart disease ?40 days post-MI with LVEF of ?35% and NYHA class II or III symptoms on chronic GDMT, who have a reasonable expectation of meaningful survival for >1 year.a .a (I-A)

ICD therapy is recommended for primary prevention of sudden cardiac death to reduce total mortality

Cardiac resynchronization therapy is indicated for patients who have LVEF of 35% or less, sinus rhythm, left bundle-branch block (LBBB) with a QRS duration of 150 ms or greater, and NYHA class II, III, or ambulatory class IV symptoms on GDMT.

ICD therapy is recommended for primary prevention of SCD to reduce total mortality in selected patients at least 40 days post-MI with LVEF of 30% or less and NYHA class I symptoms while receiving GDMT, who have a reasonable expectation of meaningful survival for more than 1 year.

ICD therapy is recommended for primary prevention of SCD to reduce total mortality

CRT can be useful in patients with AF and LVEF of ?35% on GDMT if a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) atrioventricular nodal ablation or pharmacological rate control will allow near 100% ventricular pacing with CRT.

The usefulness of implantation of an ICD is of uncertain benefit to prolong meaningful survival in patients with a high risk of nonsudden death as predicted by frequent hospitalizations, advanced frailty, or comorbidities such as systemic malignancy or severe renal dysfunction.

The usefulness of implantation of an ICD is of uncertain benefit to prolong meaningful survival

Continuous intravenous inotropic support is reasonable as “bridge therapy” in patients with stage D Heart Failure refractory to GDMT and device therapy who are eligible for and awaiting MCS or cardiac transplantation.

Continuous intravenous inotropic support is reasonable as “bridge therapy”

Long-term, continuous intravenous inotropic support may be considered as palliative therapy for symptom control in select patients with stage D Heart Failure despite optimal GDMT and device therapy who are not eligible for either MCS or cardiac transplantation.

Long-term, continuous intravenous inotropic support may be considered as palliative therapy for symptom control

Long-term use of either continuous or intermittent, intravenous parenteral positive inotropic agents, in the absence of specific indications or for reasons other than palliative care, is potentially harmful in the patient with Heart Failure.

Long-term use of either continuous or intermittent, intravenous parenteral positive inotropic agents is potentially harmful

Use of parenteral inotropic agents in hospitalized patients without documented severe systolic dysfunction, low blood pressure, or impaired perfusion, and evidence of significantly depressed cardiac output, with or without congestion, is potentially harmful.

Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices, is reasonable as a “bridge to recovery” or a “bridge to decision” for carefully selecteda Heart FailurerEF a H patients with acute, profound hemodynamic compromise.

Nondurable MCS, including the use of percutaneous and extracorporeal ventricular assist devices, is reasonable as a “bridge to recovery” or a “bridge to decision”

ACS precipitating acute Heart Failure decompensation should be promptly identified by ECG and serum biomarkers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient.

should be promptly identified by ECG and serum biomarkers, including cardiac troponin testing,

ACS precipitating acute Heart Failure decompensation should be promptly identified by ECG and serum biomarkers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient.

and treated optimally as appropriate to the overall condition and prognosis of the patient.

In patients with Heart FailurerEF experiencing a symptomatic exacerbation of Heart Failure requiring hospitalization during chronic maintenance treatment with GDMT, it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications.

it is recommended that GDMT be continued in the absence of hemodynamic instability or contraindications.

Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients.

Initiation of beta-blocker therapy is recommended after optimization of volume status and successful discontinuation of intravenous diuretics, vasodilators, and inotropic agents. Beta-blocker therapy should be initiated at a low dose and only in stable patients.

The effect of Heart Failure treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of Heart Failure medications.

The effect of HF treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion

The effect of Heart Failure treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of Heart Failure medications.

Daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of HF medications.

When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. Higher doses of intravenous loop diuretics (IIa-B), or b. Addition of a second (eg, thiazide) diuretic (IIa-B).

it is reasonable to intensify the diuretic regimen using higher doses of intravenous loop diuretics

When diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. Higher doses of intravenous loop diuretics (IIa-B), or b. Addition of a second (eg, thiazide) diuretic (IIa-B).

it is reasonable to intensify the diuretic regimen using addition of a second (eg, thiazide) diuretic

If symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acute decompensated Heart Failure.

intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as an adjuvant to diuretic therapy for relief of dyspnea

In patients hospitalized with volume overload, including Heart Failure, who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of GDMT, vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor–selective or a nonselective vasopressin antagonist.

vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a V2 receptor–selective or a nonselective vasopressin antagonist

The use of performance improvement systems and/or evidence-based systems of care is recommended in the hospital and early postdischarge outpatient setting to identify appropriate Heart Failure patients for GDMT, provide clinicians with useful reminders to advance GDMT, and assess the clinical response.

The use of performance improvement systems and/or evidence-based systems of care is recommended

Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (I-B): a. Initiation of GDMT if not previously established and not contraindicated b. Precipitant causes of Heart Failure, barriers to optimal care transitions, and limitations in postdischarge support c. Assessment of volume status and supine/upright hypotension with adjustment of Heart Failure therapy, as appropriate d. Titration and optimization of chronic oral Heart Failure therapy e. Assessment of renal function and electrolytes, where appropriate f. Assessment and management of comorbid conditions g. Reinforcement of Heart Failure education, self-care, emergency plans, and need for adherence h. Consideration for palliative care or hospice care in selected patients

Initiation of GDMT if not previously established and not contraindicated b.

Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (I-B): a. Initiation of GDMT if not previously established and not contraindicated b. Precipitant causes of Heart Failure, barriers to optimal care transitions, and limitations in postdischarge support c. Assessment of volume status and supine/upright hypotension with adjustment of Heart Failure therapy, as appropriate d. Titration and optimization of chronic oral Heart Failure therapy e. Assessment of renal function and electrolytes, where appropriate f. Assessment and management of comorbid conditions g. Reinforcement of Heart Failure education, self-care, emergency plans, and need for adherence h. Consideration for palliative care or hospice care in selected patients

Precipitant causes of HF, barriers to optimal care transitions, and limitations in postdischarge support c.

Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (I-B): a. Initiation of GDMT if not previously established and not contraindicated b. Precipitant causes of Heart Failure, barriers to optimal care transitions, and limitations in postdischarge support c. Assessment of volume status and supine/upright hypotension with adjustment of Heart Failure therapy, as appropriate d. Titration and optimization of chronic oral Heart Failure therapy e. Assessment of renal function and electrolytes, where appropriate f. Assessment and management of comorbid conditions g. Reinforcement of Heart Failure education, self-care, emergency plans, and need for adherence h. Consideration for palliative care or hospice care in selected patients

Assessment of volume status and supine/upright hypotension with adjustment of HF therapy, as appropriate

Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (I-B): a. Initiation of GDMT if not previously established and not contraindicated b. Precipitant causes of Heart Failure, barriers to optimal care transitions, and limitations in postdischarge support c. Assessment of volume status and supine/upright hypotension with adjustment of Heart Failure therapy, as appropriate d. Titration and optimization of chronic oral Heart Failure therapy e. Assessment of renal function and electrolytes, where appropriate f. Assessment and management of comorbid conditions g. Reinforcement of Heart Failure education, self-care, emergency plans, and need for adherence h. Consideration for palliative care or hospice care in selected patients

Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (I-B): a. Initiation of GDMT if not previously established and not contraindicated b. Precipitant causes of Heart Failure, barriers to optimal care transitions, and limitations in postdischarge support c. Assessment of volume status and supine/upright hypotension with adjustment of Heart Failure therapy, as appropriate d. Titration and optimization of chronic oral Heart Failure therapy e. Assessment of renal function and electrolytes, where appropriate f. Assessment and management of comorbid conditions g. Reinforcement of Heart Failure education, self-care, emergency plans, and need for adherence h. Consideration for palliative care or hospice care in selected patients

Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (I-B): a. Initiation of GDMT if not previously established and not contraindicated b. Precipitant causes of Heart Failure, barriers to optimal care transitions, and limitations in postdischarge support c. Assessment of volume status and supine/upright hypotension with adjustment of Heart Failure therapy, as appropriate d. Titration and optimization of chronic oral Heart Failure therapy e. Assessment of renal function and electrolytes, where appropriate f. Assessment and management of comorbid conditions g. Reinforcement of Heart Failure education, self-care, emergency plans, and need for adherence h. Consideration for palliative care or hospice care in selected patients

Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (I-B): a. Initiation of GDMT if not previously established and not contraindicated b. Precipitant causes of Heart Failure, barriers to optimal care transitions, and limitations in postdischarge support c. Assessment of volume status and supine/upright hypotension with adjustment of Heart Failure therapy, as appropriate d. Titration and optimization of chronic oral Heart Failure therapy e. Assessment of renal function and electrolytes, where appropriate f. Assessment and management of comorbid conditions g. Reinforcement of Heart Failure education, self-care, emergency plans, and need for adherence h. Consideration for palliative care or hospice care in selected patients

Throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (I-B): a. Initiation of GDMT if not previously established and not contraindicated b. Precipitant causes of Heart Failure, barriers to optimal care transitions, and limitations in postdischarge support c. Assessment of volume status and supine/upright hypotension with adjustment of Heart Failure therapy, as appropriate d. Titration and optimization of chronic oral Heart Failure therapy e. Assessment of renal function and electrolytes, where appropriate f. Assessment and management of comorbid conditions g. Reinforcement of Heart Failure education, self-care, emergency plans, and need for adherence h. Consideration for palliative care or hospice care in selected patients

Consideration for palliative care or hospice care in selected patients

Multidisciplinary Heart Failure disease-management programs are recommended for patients at high risk for hospital readmission, to facilitate the implementation of GDMT, to address different barriers to behavioral change, and to reduce the risk of subsequent rehospitalization for Heart Failure.

CABG may be considered with the intent of improving survival in patients with ischemic heart disease with severe LV systolic dysfunction (EF <35%) and operable coronary anatomy whether or not viable myocardium is present. (IIb-B)

Transcatheter mitral valve repair or mitral valve surgery for functional mitral insufficiency is of uncertain benefit and should only be considered after careful candidate selection and with a background of GDMT.

Transcatheter mitral valve repair or mitral valve surgery for functional mitral insufficiency is of uncertain benefit and should only be considered

Surgical reverse remodeling or LV aneurysmectomy may be considered in carefully selected patients with Heart FailurerEF for specific indications including intractable Heart Failure and ventricular arrhythmias.

Surgical reverse remodeling or LV aneurysmectomy may be considered in carefully selected patients with Heart FailurerEF for specific indications including intractable Heart Failure and ventricular arrhythmias.

Effective systems of care coordination with special attention to care transitions should be deployed for every patient with chronic Heart Failure that facilitate and ensure effective care that is designed to achieve GDMT and prevent hospitalization.

Effective systems of care coordination with special attention to care transitions should be deployed

Every patient with Heart Failure should have a clear, detailed, and evidencebased plan of care that ensures the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient’s healthcare team. (I-C)

Every patient with Heart Failure should have a clear, detailed, and evidencebased plan of care that ensures the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient’s healthcare team. (I-C)

Every patient with Heart Failure should have a clear, detailed, and evidencebased plan of care that ensures the achievement of GDMT goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. This plan of care should be updated regularly and made readily available to all members of each patient’s healthcare team. (I-C)

made readily available to all members of each patient’s healthcare team

Participation in quality improvement programs and patient registries based on nationally endorsed, clinical practice guideline–based quality and performance measures can be beneficial in improving quality of Heart Failure care.

Participation in quality improvement programs and patient registries based on nationally endorsed, clinical practice guideline–based quality and performance measures can be beneficial

Hospital-Acquired and VentilatorAssociated Pneumonia

32654

We suggest noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than invasive sampling with quantitative cultures and rather than noninvasive sampling with quantitative cultures

perform noninvasive sampling with semiquantitative cultures

perform

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32654

We suggest noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than invasive sampling with quantitative cultures and rather than noninvasive sampling with quantitative cultures

invasive sampling with quantitative cultures

perform

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32654

We suggest noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than invasive sampling with quantitative cultures and rather than noninvasive sampling with quantitative cultures

noninvasive sampling with quantitative cultures

perform

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32655

Noninvasive sampling with semiquantitative cultures is the preferred methodology to diagnose VAP (see section I); however, the panel recognizes that invasive quantitative cultures will occasionally be performed by some clinicians. For patients with suspected VAP whose invasive quantitative culture results are below the diagnostic threshold for VAP, we suggest that antibiotics be withheld rather than continued

withhold antibiotics rather than continuing

withhold

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32656

We suggest that patients with suspected HAP (non-VAP) be treated according to the results of microbiologic studies performed on respiratory samples obtained noninvasively, rather than being treated empirically

treat according to the results of microbiologic studies performed on respiratory samples obtained noninvasively

Hospital-Acquired and VentilatorAssociated Pneumonia

32656

We suggest that patients with suspected HAP (non-VAP) be treated according to the results of microbiologic studies performed on respiratory samples obtained noninvasively, rather than being treated empirically

treat with empiric antibiotic therapy

Hospital-Acquired and VentilatorAssociated Pneumonia

32657

For patients with suspected HAP/VAP, we recommend using clinical criteria alone, rather than using serum PCT plus clinical criteria, to decide whether or not to initiate antibiotic therapy

use clinical criteria alone to decide whether or not to initiate antibiotic therapy

use

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32657

For patients with suspected HAP/VAP, we recommend using clinical criteria alone, rather than using serum PCT plus clinical criteria, to decide whether or not to initiate antibiotic therapy

use serum PCT plus clinical criteria

use

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32658

For patients with suspected HAP/VAP, we recommend using clinical criteria alone, rather than using bronchoalveolar lavage fluid (BALF) sTREM-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy

using clinical criteria alone to decide whether or not to initiate antibiotic therapy

use

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32658

For patients with suspected HAP/VAP, we recommend using clinical criteria alone, rather than using bronchoalveolar lavage fluid (BALF) sTREM-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy

For patients with suspected HAP/VAP, we recommend using clinical criteria alone rather than using CRP plus clinical criteria, to decide whether or not to initiate antibiotic therapy

use clinical criteria alone to decide whether or not to initiate antibiotic therapy

use

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32659

For patients with suspected HAP/VAP, we recommend using clinical criteria alone rather than using CRP plus clinical criteria, to decide whether or not to initiate antibiotic therapy

use CRP plus clinical criteria

use

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32660

For patients with suspected HAP/VAP, we suggest using clinical criteria alone, rather than using CPIS plus clinical criteria, to decide whether or not to initiate antibiotic therapy

use clinical criteria alone to decide whether or not to initiate antibiotic therapy

use

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32660

For patients with suspected HAP/VAP, we suggest using clinical criteria alone, rather than using CPIS plus clinical criteria, to decide whether or not to initiate antibiotic therapy

use CPIS plus clinical criteria

use

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32661

In patients with VAT, we suggest not providing antibiotic therapy

do not provide antibiotic therapy

provide

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32662

In patients with suspected VAP, we recommend including coverage for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens

including coverage for S. aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens

including

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32663

We suggest including an agent active against MRSA for the empiric treatment of suspected VAP only in patients with any of the following: a risk factor for antimicrobial resistance (Table 2), patients being treated in units where >10%–20% of S. aureus isolates are methicillin resistant, and patients in units where the prevalence of MRSA is not known

including an agent active against MRSA for the empiric treatment of suspected VAP

include

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32664

We suggest including an agent active against methicillinsensitive S. aureus (MSSA) (and not MRSA) for the empiric treatment of suspected VAP in patients without risk factors for antimicrobial resistance, who are being treated in ICUs where <10%–20% of S. aureus isolates are methicillin resistant (weak recommendation, very low-quality evidence).

including an agent active against methicillinsensitive S. aureus (MSSA) (and not MRSA) for the empiric treatment of suspected VAP

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32665

If empiric coverage for MRSA is indicated, we recommend either vancomycin or linezolid

treat with vancomycin

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32665

If empiric coverage for MRSA is indicated, we recommend either vancomycin or linezolid

treat with linezolid

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32666

When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). Oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven MSSA, but are not necessary for the empiric treatment of VAP if one of the above agents is used.

a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem

treat

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32667

When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). Oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven MSSA, but are not necessary for the empiric treatment of VAP if one of the above agents is used.

a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem

treat

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32666

Oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven MSSA, but are not necessary for the empiric treatment of VAP if one of the above agents is used

Oxacillin, nafcillin, or cefazolin are preferred agents but are not necessary for the empiric treatment of VAP if one of the above agents is used

Hospital-Acquired and VentilatorAssociated Pneumonia

32667

Oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven MSSA, but are not necessary for the empiric treatment of VAP if one of the above agents is used

Oxacillin, nafcillin, or cefazolin are preferred agents but are not necessary for the empiric treatment of VAP if one of the above agents is used

Hospital-Acquired and VentilatorAssociated Pneumonia

32668

We suggest prescribing 2 antipseudomonal antibiotics from different classes for the empiric treatment of suspected VAP only in patients with any of the following: a risk factor for antimicrobial resistance (Table 2), patients in units where >10% of gram-negative isolates are resistant to an agent being considered for monotherapy, and patients in an ICU where local antimicrobial susceptibility rates are not available

prescribe 2 antipseudomonal antibiotics from different classes

prescibe

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32669

We suggest prescribing one antibiotic active against P. aeruginosa for the empiric treatment of suspected VAP in patients without risk factors for antimicrobial resistance who are being treated in ICUs where ?10% of gram-negative isolates are resistant to the agent being considered for monotherapy

prescribing one antibiotic active against P. aeruginosa

prescribe

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32670

In patients with suspected VAP, we suggest avoiding aminoglycosides if alternative agents with adequate gram-negative activity are available

avoid aminoglycosides

avoid

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32671

In patients with suspected VAP, we suggest avoiding colistin if alternative agents with adequate gram-negative activity are available

avoiding colistin

avoid

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32672

For patients being treated empirically for HAP, we recommend prescribing an antibiotic with activity against S. aureus

prescribing an antibiotic with activity against S. aureus

prescribing

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32673

For patients with HAP who are being treated empirically and have either a risk factor for MRSA infection (ie, prior intravenous antibiotic use within 90 days, hospitalization in a unit where >20% of S. aureus isolates are methicillin resistant, or the prevalence of MRSA is not known, or who are at high risk for mortality, we suggest prescribing an antibiotic with activity against MRSA

prescribing an antibiotic with activity against MRSA

prescribe

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32674

For patients with HAP who require empiric coverage for MRSA, we recommend vancomycin or linezolid rather than an alternative antibiotic

treat with vancomycin or linezolid rather than an alternative antibiotic

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32675

For patients with HAP who are being treated empirically and have no risk factors for MRSA infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against MSSA. When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. Oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven MSSA, but are not necessary for empiric coverage of HAP if one of the above agents is used

prescribing an antibiotic with activity against MSSA.

Hospital-Acquired and VentilatorAssociated Pneumonia

32676

For patients with HAP who are being treated empirically and have no risk factors for MRSA infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against MSSA. When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. Oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven MSSA, but are not necessary for empiric coverage of HAP if one of the above agents is used

prescribing an antibiotic with activity against MSSA.

Hospital-Acquired and VentilatorAssociated Pneumonia

32675

When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. Oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven MSSA, but are not necessary for empiric coverage of HAP if one of the above agents is used

a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem.

Hospital-Acquired and VentilatorAssociated Pneumonia

32676

When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. Oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven MSSA, but are not necessary for empiric coverage of HAP if one of the above agents is used

a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem.

Hospital-Acquired and VentilatorAssociated Pneumonia

32677

For patients with HAP who are being treated empirically, we recommend prescribing antibiotics with activity against P. aeruginosa and other gram-negative bacilli

prescribing antibiotics with activity against P. aeruginosa and other gram-negative bacilli

prescribe

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32678

For patients with HAP who are being treated empirically and have factors increasing the likelihood for Pseudomonas or other gram-negative infection (ie, prior intravenous antibiotic use within 90 days; also see Remarks) or a high risk for mortality, we suggest prescribing antibiotics from 2 different classes with activity against P. aeruginosa

prescribing antibiotics from 2 different classes with activity against P. aeruginosa

Hospital-Acquired and VentilatorAssociated Pneumonia

32679

For patients with HAP who are being treated empirically, we recommend not using an aminoglycoside as the sole antipseudomonal agent

not using an aminoglycoside as the sole antipseudomonal agent

not use

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32680

For patients with HAP/VAP, we suggest that antibiotic dosing be determined using PK/PD data, rather than the manufacturer’s prescribing information

antibiotic dosing be determined using PK/PD data, rather than the manufacturer’s prescribing information

determine

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32681

For patients with VAP due to gram-negative bacilli that are susceptible to only aminoglycosides or polymyxins (colistin or polymyxin B), we suggest both inhaled and systemic antibiotics, rather than systemic antibiotics alone

use both inhaled and systemic antibiotics, rather than systemic antibiotics alone

use

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32682

We recommend that MRSA HAP/VAP be treated with either vancomycin or linezolid rather than other antibiotics or antibiotic combinations

treated with either vancomycin or linezolid rather than other antibiotics or antibiotic combinations

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32683

For patients with HAP/VAP due to P. aeruginosa, we recommend that the choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing

choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing

choose

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32684

For patients with HAP/VAP due to P. aeruginosa, we recommend against aminoglycoside monotherapy (strong recommendation, very low-quality evidence).

against treating with aminoglycoside monotherapy

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32685

For patients with HAP/VAP due to P. aeruginosa who are not in septic shock or at a high risk for death, and for whom the results of antibiotic susceptibility testing are known, we recommend monotherapy using an antibiotic to which the isolate is susceptible rather than combination therapy

treat with monotherapy using an antibiotic to which the isolate is susceptible rather than combination therapy

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32686

For patients with HAP/VAP due to P. aeruginosa who remain in septic shock or at a high risk for death when the results of antibiotic susceptibility testing are known, we suggest combination therapy using 2 antibiotics to which the isolate is susceptible rather than monotherapy

treat with combination therapy using 2 antibiotics to which the isolate is susceptible rather than monotherapy

treat

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32687

For patients with HAP/VAP due to P. aeruginosa, we recommend against aminoglycoside monotherapy

against treating with aminoglycoside monotherapy

Hospital-Acquired and VentilatorAssociated Pneumonia

32688

For patients with HAP/VAP due to ESBL-producing gramnegative bacilli, we recommend that the choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing and patient-specific factors

the choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing and patient-specific factors

choose

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32689

In patients with HAP/VAP caused by Acinetobacter species, we suggest treatment with either a carbapenem or ampicillin/sulbactam if the isolate is susceptible to these agents

treatment with either a carbapenem or ampicillin/sulbactam

treat

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32690

In patients with HAP/VAP caused by Acinetobacter species that is sensitive only to polymyxins, we recommend intravenous polymyxin (colistin or polymyxin B)

treat with intravenous polymyxin (colistin or polymyxin B)

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32691

In patients with HAP/VAP caused by Acinetobacter species that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin

treat with adjunctive inhaled colistin

treat

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32692

In patients with HAP/VAP caused by Acinetobacter species that is sensitive only to colistin, we suggest not using adjunctive rifampicin

do not treat with adjunctive rifampicin

treat

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32693

In patients with HAP/VAP caused by Acinetobacter species, we recommend against the use of tigecycline

against the use of tigecycline

use

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32694

In patients with HAP/VAP caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we recommend intravenous polymyxins (colistin or polymyxin B)

treat with intravenous polymyxins (colistin or polymyxin B)

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32695

In patients with HAP/VAP caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin

treat with adjunctive inhaled colistin

treat

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32696

For patients with VAP, we recommend a 7-day course of antimicrobial therapy rather than a longer duration

treat with a 7-day course of antimicrobial therapy rather than a longer duration

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32697

For patients with HAP, we recommend a 7-day course of antimicrobial therapy

treat with a 7-day course of antimicrobial therapy

treat

recommend

Hospital-Acquired and VentilatorAssociated Pneumonia

32698

For patients with HAP/VAP, we suggest that antibiotic therapy be de-escalated rather than fixed

antibiotic therapy be de-escalated rather than fixed

de-escalate

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32699

For patients with HAP/VAP, we suggest using PCT levels plus clinical criteria to guide the discontinuation of antibiotic therapy, rather than clinical criteria alone

using PCT levels plus clinical criteria to guide the discontinuation of antibiotic therapy, rather than clinical criteria alone

use

suggest

Hospital-Acquired and VentilatorAssociated Pneumonia

32700

For patients with suspected HAP/VAP, we suggest not using the CPIS to guide the discontinuation of antibiotic therapy

not using the CPIS to guide the discontinuation of antibiotic therapy

use

suggest

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32701

Gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma are recommended to help identify whether Staphylococcus aureus and/or a ?-hemolytic streptococcus is the cause

use gram stain and culture of the pus or exudates from skin lesions to identify whether Staphylococcus aureus and/or a ?-hemolytic streptococcus is the cause

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32702

Treatment without gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma is reasonable in typical cases

it is reasonable in typical cases to treat without identifying whether Staphylococcus aureus and/or a ?-hemolytic streptococcus is the cause

Treat

reasonable

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32703

Treatment of bullous and nonbullous impetigo should be with either mupirocin or retapamulin bid for 5 days

treatment with either mupirocin or retapamulin twice daily for 5 days

treat

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32704

Oral therapy for ecthyma or impetigo should be a 7-day regimen with an agent active against S. aureus unless cultures yield streptococci alone (when oral penicillin is the recommended agent)

Oral therapy should be a 7-day regimen with an agent active against S. aureus

treat

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32704

Oral therapy for ecthyma or impetigo should be a 7-day regimen with an agent active against S. aureus unless cultures yield streptococci alone (when oral penicillin is the recommended agent)

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32705

Because Staphylococcus aureus isolates from impetigo and ecthyma are usually methicillin-susceptible, dicloxacillin or cephalexin is recommended.

use dicloxacillin

use

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32706

Because Staphylococcus aureus isolates from impetigo and ecthyma are usually methicillin-susceptible, dicloxacillin or cephalexin is recommended.

use dicloxacillin

use

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32705

Because Staphylococcus aureus isolates from impetigo and ecthyma are usually methicillin-susceptible, dicloxacillin or cephalexin is recommended.

use cephalexin

use

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32706

Because Staphylococcus aureus isolates from impetigo and ecthyma are usually methicillin-susceptible, dicloxacillin or cephalexin is recommended.

use cephalexin

use

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32705

When methicillin-resistant Staphylococcus aureus is suspected or confirmed, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim is recommended

use doxycycline

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32706

When methicillin-resistant Staphylococcus aureus is suspected or confirmed, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim is recommended

use doxycycline

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32705

When methicillin-resistant Staphylococcus aureus is suspected or confirmed, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim is recommended

use clindamycin

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32706

When methicillin-resistant Staphylococcus aureus is suspected or confirmed, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim is recommended

use clindamycin

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32705

When methicillin-resistant Staphylococcus aureus is suspected or confirmed, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim is recommended

use sulfamethoxazole-trimethoprim

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32706

When methicillin-resistant Staphylococcus aureus is suspected or confirmed, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim is recommended

use sulfamethoxazole-trimethoprim

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32707

Systemic antimicrobials should be used for infections during outbreaks of post-streptococcal glomerulonephritis to help eliminate nephritogenic strains of Streptococcus pyogenes from the community

systemic antimicrobials should be used for infections to help eliminate nephritogenic strains of Streptococcus pyogenes from the community

use

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32708

Gram stain and culture of pus from carbuncles and abscesses are recommended, but treatment without these studies is reasonable in typical cases

use gram stain and culture of pus

treat

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32708

Gram stain and culture of pus from carbuncles and abscesses are recommended, but treatment without these studies is reasonable in typical cases

treatment without these studies is reasonable in typical cases

treat

reasonable

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32709

Gram stain and culture of pus from inflamed epidermoid cysts are NOT recommended

Gram stain and culture of pus are NOT recommended

treat

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32710

Incision and drainage is the recommended treatment for inflamed epidermoid cysts, carbuncles, abscesses and large furuncles

treat by incision and drainage

treat

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32711

The decision to administer antibiotics directed against S. aureus as an adjunct to incision and drainage should be made based on the presence or absence of systemic inflammatory response syndrome (SIRS) such as temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia >90 beats/min or white blood cell count (WBC) >12,000 or <4000 cells/mm3

administer antibiotics directed against S. aureus as an adjunct to incision and drainage

administer

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32712

An antibiotic active against MRSA is recommended for patients with carbuncles or abscesses who have failed initial antibiotic treatment, have markedly impaired host defenses, or in patients with SIRS and hypotension

use an antibiotic active against MRSA (

use

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32713

A recurrent abscess at a site of previous infection should prompt a search for local causes such as a pilonidal cyst, hidradenitis suppurativa or foreign material

search for local causes such as a pilonidal cyst, hidradenitis suppurativa or foreign material

search

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32714

Recurrent abscesses should be drained and cultured early in the course of infection

recurrent abscesses should be drained and cultured

drain

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32715

After obtaining cultures of recurrent abscess, treat with a 5- to 10-day course of an antibiotic active against the pathogen isolated

treat with a 5- to 10-day course of an antibiotic active against the pathogen isolated

treat

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32717

Adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood

adult patients should be evaluated for neutrophil disorders

evaluate

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32718

Cultures of blood or cutaneous aspirates, biopsies, or swabs are NOT routinely recommended

do not obtain cultures of blood

do not obtain

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32718

Cultures of blood or cutaneous aspirates, biopsies, or swabs are NOT routinely recommended

do not obtain cutaneous aspirates

do not obtain

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32718

Cultures of blood or cutaneous aspirates, biopsies, or swabs are NOT routinely recommended

do not obtain biopsies

do not obtain

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32718

Cultures of blood or cutaneous aspirates, biopsies, or swabs are NOT routinely recommended

do not obtain swabs

do not obtain

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32719

Cultures of blood are recommended in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites

obtain cultures of blood

obtain

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32720

cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (

obtain cultures of blood

obtain

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32720

cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (

obtain microscopic examination of cutaneous aspirates

obtain

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32720

cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (

obtain biopsies

obtain

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32720

cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (

obtain swabs

obtain

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32721

Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci

should receive an antimicrobial agent that is active against streptococci

receive

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32722

For cellulitis with systemic signs of infection (See Fig. 1/Nonpurulent/MODERATE) systemic antibiotics are indicated. Many clinicians could include coverage against methicillin-susceptible S. aureus (MSSA) (

systemic antibiotics are indicated

prescribe

indicated

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32723

For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended

vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended

prescribe

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32724

In severely compromised patients (patients who have failed oral antibiotic treatment or those with systemic signs of infection (such as temperature >38°C, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (<12 000 or <400 cells/?L), or those who are immunocompromised,or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction) broad-spectrum antimicrobial coverage may be considered

broad-spectrum antimicrobial coverage may be considered

consider

may

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32725

Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem is recommended as a reasonable empiric regimen for severe infections

Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem is recommended as a reasonable empiric regimen

prescribe

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32726

The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period

treatment should be extended

extend

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32727

Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended

Elevation of the affected area

elevate

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32727

Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended

treat predisposing factors, such as edema or underlying cutaneous disorders

treat

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32728

In lower extremity cellulitis, clinicians should carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection

carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection

examine

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32729

Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability

Outpatient therapy is recommended

perform

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32730

Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient or if outpatient treatment is failing

hospitalization is recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32731

Systemic corticosteroids (eg, prednisone 40 mg daily for 7 days) could be considered in nondiabetic adult patients with cellulitis

Systemic corticosteroids (eg, prednisone 40 mg daily for 7 days) could be considered

prescribe

consider

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32732

Identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities. These practices should be performed as part of routine patient care and certainly during the acute stage of cellulitis.

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32733

Administration of prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4-52 weeks, or intramuscular benzathine penicillin every 2-4 weeks should be considered in patients who have 3-4 episodes of cellulitis per year despite attempts to treat or control predisposing factors

administer prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4-52 weeks

administer

should be considered

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32733

Administration of prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4-52 weeks, or intramuscular benzathine penicillin every 2-4 weeks should be considered in patients who have 3-4 episodes of cellulitis per year despite attempts to treat or control predisposing factors

intramuscular benzathine penicillin every 2-4 weeks

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32734

This program should be continued so long as the predisposing factors persist

administration of prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4-52 weeks, or intramuscular benzathine penicillin every 2-4 weeks should be continued

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32735

Suture removal plus incision and drainage should be performed for surgical site infections

Suture removal plus incision and drainage should be performed

perform

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32736

Adjunctive systemic antimicrobial therapy is NOT routinely indicated but in conjunction with incision and drainage may be beneficial for surgical site infections associated with a significant systemic response such as erythema and induration extending >5 cm from the wound edge, temperature >38.5ºC, heart rate >110/min, or WBC count >12,000/mm3

Adjunctive systemic antimicrobial therapy is NOT routinely indicated but in conjunction with incision and drainage may be beneficial

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32737

A brief course of systemic antimicrobial therapy is indicated in patients with surgical site infections after clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection

a brief course of systemic antimicrobial therapy is indicated

perform

indicated

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32738

A first-generation cephalosporin or an anti-staphylococcal penicillin for MSSA or vancomycin, linezolid, daptomycin, telavancin or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics) is recommended

use a first-generation cephalosporin

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32738

A first-generation cephalosporin or an anti-staphylococcal penicillin for MSSA or vancomycin, linezolid, daptomycin, telavancin or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics) is recommended

use an anti-staphylococcal penicillin for MSSA

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32738

A first-generation cephalosporin or an anti-staphylococcal penicillin for MSSA or vancomycin, linezolid, daptomycin, telavancin or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics) is recommended

use vancomycin

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32738

A first-generation cephalosporin or an anti-staphylococcal penicillin for MSSA or vancomycin, linezolid, daptomycin, telavancin or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics) is recommended

use linezolid

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32738

A first-generation cephalosporin or an anti-staphylococcal penicillin for MSSA or vancomycin, linezolid, daptomycin, telavancin or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics) is recommended

use daptomycin

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32738

A first-generation cephalosporin or an anti-staphylococcal penicillin for MSSA or vancomycin, linezolid, daptomycin, telavancin or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics) is recommended

use telavancin

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32738

A first-generation cephalosporin or an anti-staphylococcal penicillin for MSSA or vancomycin, linezolid, daptomycin, telavancin or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics) is recommended

use ceftaroline

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32739

Agents active against Gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections after operations on the axilla, gastrointestinal (GI) tract, perineum or female genital tract

Agents active against Gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32740

Prompt surgical consultation is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene

prompt surgical consultation

consult

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32741

Empiric antibiotic treatment should be broad (eg, vancomycin or linezolid plus piperacillin-tazobactam or plus a carbapenem; or plus ceftriaxone and metronidazole), since the etiology can be polymicrobial (mixed aerobic-anaerobic microbes) or monomicrobial (Group A streptococcus, community-acquired MRSA)

empiric antibiotic treatment should be broad (eg, vancomycin or linezolid plus piperacillin-tazobactam or plus a carbapenem; or plus ceftriaxone and metronidazole), since the etiology can be polymicrobial (mixed aerobic-anaerobic microbes) or monomicrobial (Group A streptococcus, community-acquired MRSA)

treat

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32742

Penicillin plus clindamycin is recommended for treatment of documented Group A streptococcal necrotizing fasciitis

use penicillin plus clindamycin

treat

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32743

Magnetic resonance imaging (MRI) is the recommended imaging modality for establishing the diagnosis of pyomyositis. Computed tomography (CT) scan and ultrasound studies are also useful.

use magnetic resonance imaging

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32743

Magnetic resonance imaging (MRI) is the recommended imaging modality for establishing the diagnosis of pyomyositis. Computed tomography (CT) scan and ultrasound studies are also useful.

computed tomography scan

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32743

Magnetic resonance imaging (MRI) is the recommended imaging modality for establishing the diagnosis of pyomyositis. Computed tomography (CT) scan and ultrasound studies are also useful.

ultrasound studies

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32744

Cultures of blood and abscess material should be obtained

obtain cultures of blood and abscess material

obtain

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32745

Vancomycin is recommended for initial empiric therapy. An agent active against enteric Gram-negative bacilli should be added for infection in immunocompromised patients or after open trauma to the muscles (SR-M).

Vancomycin is recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32745

Vancomycin is recommended for initial empiric therapy. An agent active against enteric Gram-negative bacilli should be added for infection in immunocompromised patients or after open trauma to the muscles (SR-M).

An agent active against enteric Gram-negative bacilli should be added for infection in immunocompromised patients or after open trauma to the muscles

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32746

Cefazolin or antistaphylococcal penicillin (eg, nafcillin or oxacillin) is recommended for treatment of pyomyositis caused by MSSA (SR-M).

Cefazolin

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32746

Cefazolin or antistaphylococcal penicillin (eg, nafcillin or oxacillin) is recommended for treatment of pyomyositis caused by MSSA (SR-M).

antistaphylococcal penicillin (eg, nafcillin or oxacillin)

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32747

Early drainage of purulent material should be performed

early drainage of purulent material should be performed

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32748

Repeat imaging studies should be performed in patients with persistent bacteremia to identify undrained foci of infection

perform repeat imaging studies

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32749

Antibiotics should be administered intravenously initially, but once the patient is clinically improved oral antibiotics are appropriate for patients in whom bacteremia cleared promptly and there is no evidence of endocarditis or metastatic abscess. Two to three weeks of therapy is recommended.

Initially administer antibiotics intravenously

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32749

Antibiotics should be administered intravenously initially, but once the patient is clinically improved oral antibiotics are appropriate for patients in whom bacteremia cleared promptly and there is no evidence of endocarditis or metastatic abscess. Two to three weeks of therapy is recommended.

Treat with oral antibiotics or metastatic abscess

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32750

Urgent surgical exploration of the suspected gas gangrene site and surgical debridement of involved tissue should be performed

perform urgent surgical exploration of the suspected gas gangrene site

perform

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32750

Urgent surgical exploration of the suspected gas gangrene site and surgical debridement of involved tissue should be performed

perform surgical debridement of involved tissue

perform

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32751

In the absence of a definitive etiologic diagnosis, broad-spectrum treatment with vancomycin plus either piperacillin/tazobactam, ampicillin/sulbactam or a carbapenem antimicrobial is recommended (SR-L).

broad-spectrum treatment with vancomycin plus either piperacillin/tazobactam, ampicillin/sulbactam or a carbapenem antimicrobial

treat

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32752

Definitive antimicrobial therapy with penicillin and clindamycin is recommended for treatment of clostridial myonecrosis (SR-L).

Definitive antimicrobial therapy with penicillin and clindamycin

perform

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32753

Hyperbaric oxygen therapy is NOT recommended because it has not been proven as a benefit to patients and may delay resuscitation and surgical debridement (SR-L).

do not use hyperbaric oxygen therapy because it has not been proven as a benefit to patients and may delay resuscitation and surgical debridement

do not use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32754

Preemptive early antimicrobial therapy for 3-5 days is recommended for patients who: a) are immunocompromised; b) are asplenic; c) have advanced liver disease; d) have preexisting or resultant edema of the affected area; e) have moderate to severe injuries, especially to the hand or face; or f) have injuries that may have penetrated the periosteum or joint capsule (SR-L).

Preemptive early antimicrobial therapy for 3-5 days

perform

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32755

Postexposure prophylaxis for rabies may be indicated. Consultation with local health officials is recommended to determine if vaccination should be initiated (SR-L).

may indicate postexposure prophylaxis for rabies

indicate

may

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32755

Postexposure prophylaxis for rabies may be indicated. Consultation with local health officials is recommended to determine if vaccination should be initiated (SR-L).

consult with local health officials to determine if vaccination should be initiated

consult

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32756

An antimicrobial agent or agents active against both aerobic and anaerobic bacteria such as amoxicillin-clavulanate should be used

use an antimicrobial agent or agents active against both aerobic and anaerobic bacteria such as amoxicillin-clavulanate

use

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32757

Tetanus toxoid should be administered to patients without toxoid vaccination within 10 years. Tdap is preferred over Td if the former has not been previously given (SR-L).

Tetanus toxoid should be administered. Tdap is preferred over Td if the former has not been previously given

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32758

Primary wound closure is NOT recommended for wounds, with the exception of those to the face, which should be managed with copious irrigation, cautious debridement and preemptive antibiotics.

use copious irrigation

use

recommended

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32758

Primary wound closure is NOT recommended for wounds, with the exception of those to the face, which should be managed with copious irrigation, cautious debridement and preemptive antibiotics.

primary wound closure

perform

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32758

Primary wound closure is NOT recommended for wounds, with the exception of those to the face, which should be managed with copious irrigation, cautious debridement and preemptive antibiotics.

cautious debridement

perform

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32758

Primary wound closure is NOT recommended for wounds, with the exception of those to the face, which should be managed with copious irrigation, cautious debridement and preemptive antibiotics.

preemptive antibiotics

use

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32759

Other wounds may be approximated (WR-L).

approximate

approximate

may

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32774

Differential diagnosis for infection of skin lesions should include bacterial, fungal, viral and parasitic agents (SR-H).

Differential diagnosis for infection of skin lesions should include bacterial, fungal, viral and parasitic agents

perform differential diagnosis

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32775

Biopsy or aspiration of the lesion to obtain material for histologic and microbiologic evaluation should always be implemented as an early diagnostic step (SR-H).

implement biopsy or aspiration of the lesion to obtain material for histologic and microbiologic evaluation as an early diagnostic step

implement

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32776

Determine whether the current presentation of fever and neutropenia is the patient’s initial episode of fever and neutropenia or a persistent unexplained fever from their initial episode (after 4-7 days), or a subsequent episode of fever and neutropenia (recurrent)

Determine whether the current presentation of fever and neutropenia is the patient’s initial episode of fever and neutropenia or a persistent unexplained fever from their initial episode (after 4-7 days), or a subsequent episode of fever and neutropenia (recurrent)

determine

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32777

Aggressively determine the etiology of the skin and soft tissue infection by aspiration and/or biopsy of skin and soft tissue lesions and submit these for thorough cytologic/histologic assessments, microbial staining and cultures

aggressively determine the etiology of the skin and soft tissue infection by aspiration and/or biopsy of skin and soft tissue lesions

determine

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32777

Aggressively determine the etiology of the skin and soft tissue infection by aspiration and/or biopsy of skin and soft tissue lesions and submit these for thorough cytologic/histologic assessments, microbial staining and cultures

submit these for thorough cytologic/histologic assessments, microbial staining, and cultures

submit

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32778

Risk-stratify patients with fever and neutropenia according to susceptibility to infection: high-risk patients are those with anticipated prolonged (>7 days) and profound neutropenia (ANC <100 cells/?L) or with a Multinational Association for Supportive Care (MASCC) score of <21; low-risk patients are those with anticipated brief (<7 days) periods of neutropenia and few comorbidities or with a MASCC of ?21

Risk-stratify patients with fever and neutropenia according to susceptibility to infection: high-risk patients are those with anticipated prolonged (>7 days) and profound neutropenia (ANC <100 cells/?L) or with a Multinational Association for Supportive Care (MASCC) score of <21; low-risk patients are those with anticipated brief (<7 days) periods of neutropenia and few comorbidities or with a MASCC of ?21

risk-stratify

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32780

Hospitalization and empiric antibacterial therapy with vancomycin plus antipseudomonal antibiotics such as cefepime, a carbapenem (imipenem-cilastatin or meropenem or doripenem) or piperacillintazobactam are recommended

hospitalize

hospitalize

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32780

Hospitalization and empiric antibacterial therapy with vancomycin plus antipseudomonal antibiotics such as cefepime, a carbapenem (imipenem-cilastatin or meropenem or doripenem) or piperacillintazobactam are recommended

perform empiric antibacterial therapy with vancomycin plus antipseudomonal antibiotics such as cefepime, a carbapenem (imipenem-cilastatin or meropenem or doripenem) or piperacillintazobactam

perform empiric antibacterial therapy

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32781

Documented clinical and microbiologic skin and soft tissue infections should be treated based on antimicrobial susceptibilities of isolated organisms

treat based on antimicrobial susceptibilities of isolated organisms

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32782

The treatment duration for most bacterial skin and soft tissue infections should be 7-14 days

treatment duration should be 7-14 days

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32783

Surgical intervention is recommended for drainage of soft-tissue abscess after marrow recovery or for a progressive polymicrobial necrotizing fasciitis or myonecrosis

perform surgical intervention for drainage of soft-tissue abscess after marrow recovery or for a progressive polymicrobial necrotizing fasciitis or myonecrosis

perform surgical procedure

recommend

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

treat with lipid formulations of amphotericin B, posaconazole, or echinocandin for 6-12 weeks

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32793

Mucor/Rhizopus infections should be treated with lipid formulation amphotericin B

treat with lipid formulation amphotericin B

treat

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32794

Mucor/Rhizopus infections should be treated with posaconazole

treat with posaconazole

treat

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32795

The addition of an echinocandin could be considered based on synergy in murine models of mucormycosis and observational clinical data (WR-L).

add echinocandin

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32796

Fusarium species infections should be treated with high-dose IV voriconazole or posaconazole

treat with high-dose IV voriconazole or posaconazole

treat

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32797

Begin treatment for antibiotic-resistant bacterial organisms (Table 6) in patients currently on antibiotics.

begin treatment for antibiotic-resistant bacterial organisms

treat

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32798

Intravenous acyclovir should be added to the patient’s antimicrobial regimen for suspected or confirmed cutaneous or disseminated HSV or VZV infections (SR-M).

add intravenous acyclovir to the patient’s antimicrobial regimen

add

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32799

Blood cultures should be obtained, and skin lesions in this population of patients should be aggressively evaluated by culture aspiration, biopsy or surgical excision since they may be caused by resistant microbes, yeast or molds

obtain blood cultures

obtain

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32799

Blood cultures should be obtained, and skin lesions in this population of patients should be aggressively evaluated by culture aspiration, biopsy or surgical excision since they may be caused by resistant microbes, yeast or molds

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32800

Polymerase chain reaction (PCR) in peripheral blood for HSV and VZV might be helpful in establishing a diagnosis of disseminated infection in patients with unexplained skin lesions (WR-M).

use polymerase chain reaction in peripheral blood for herpes simplex virus and varicella zoster virus to establish a diagnosis of disseminated infection

use

might

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32801

Consider immediate consultation with a dermatologist familiar with cutaneous manifestations of infection in patients with cellular immune defects (eg, those with lymphoma, lymphocytic leukemia, recipients of organ transplants, or those receiving immunosuppressive drugs such as anti-tumor necrosis factors or certain monoclonal antibodies)

Consider immediate consultation with a dermatologist familiar with cutaneous manifestations of infection

consult

consider

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32802

Consider biopsy and surgical debridement early in the management of these patients

perform biopsy

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32802

Consider biopsy and surgical debridement early in the management of these patients

perform surgical debridement

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32803

Empiric antibiotics, antifungals and/or antivirals should be considered

use empiric antibiotics, antifungals and/or antivirals

use

should

Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America

32804

The use of specific agents should be decided with the input of the primary team, dermatology, infectious disease and other consulting teams

The use of specific agents should be decided with the input of the primary team, dermatology, infectious disease, and other consulting teams